Privacy Policy

THIS NOTICE DESCRIBES HOW CHIROPRACTIC AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TOTHIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Our Responsibilities The Chicago Body Works (hence, CBW) is required to maintain the privacy of your health Information. This includes medical information about you that is collected during the course of your treatment, such as your symptoms, examination and test results, diagnoses, treatment, and a plan for future care. Information about care that you have received from other providers may also be included in CBW’s medical record. Health Information also includes demographic information and payment information. We are required by law to provide you with this Notice of Privacy Practices. This Notice describes how we use your Health Information at CBW, and disclose (share) it with others as necessary outside our offices. CBW must abide by the terms of the Notice currently in effect. We reserve the right to change the terms of our Notice and to make the new Notice provisions effective for all Health Information that it maintains. We will post our current Notice in a prominent location in each of our practice sites, as well as on our website: www.thechicagobodyworks.com.

Uses and Disclosures of your Health Information The following are examples of the types of uses and disclosures of your Health Information that CBW is legally permitted to make, as necessary, without your specific authorization:

A. Uses and Disclosures of Health Information for Treatments, Payment and Operations 1. Treatment: Your Health Information may be used and disclosed by your chiropractor and the CBW staff who are involved in your care and treatment. In addition, your chiropractor or a staff member may have to disclose your health information, including all of your clinical records, to another health care provider or a hospital if it is necessary to refer you to them for diagnosis, assessment or treatment of your health condition. We believe this is critical to provide you the very best in health care and is necessary, given the complexities of various health conditions. 2. Payment: Our insurance and billing staff may use and disclose your Health Information, as needed, to obtain payment for health care services. We may have to disclose your examination and treatment records and your billing records to another party, such as an insurance carrier, an HMO, a PPO or your employer, if they are potentially responsible for the payment of your services. We may disclose information to your insurance company or a third party payer in order to make sure your treatment is approved, to verify eligibility or coverage for insurance benefits, and to permit the payer to review services provided to you for medical necessity. 3. Operations: Your chiropractor and members of the staff may need to use your HealthInformation, examination and treatment records and your billing records for quality control purposes or for other administrative purposes to efficiently and effectively run our practice. In addition, unless you ask us not to, we will contact you to remind you of your appointments with us. If you are not home to receive an appointment reminder, a message will be left on your answering machine. We may also provide you with information about treatment alternatives or other health-related benefits, products and services that may be beneficial to you, again, with the hopes of improving your health and welfare.

B. Other Permitted and Required Uses and Disclosures of your Health Information Under Federal law, we are also permitted or required to use or disclose your Health Information without your consent or authorization in these following circumstances: 1. If we are providing health care services to you based on the orders of another health care provider, 2. If we provide health care services to you as an inmate, 3. If we provide health care services to you in an emergency, 4. If we are required by law to treat you and we are unable to obtain your consent after attempting to do so, 5. If there are substantial barriers to communicating with you, but in our professional judgment we believe that you intend for us to provide care, 6. For reasons of Public Health, for example, to report reactions to medications or problems with products, or that you have been exposed to a communicable disease, 7. In the course of any judicial or administrative proceeding in response to a legal order or other lawful process, including a subpoena, 8. For law enforcement purposes 9. To a health oversight agency for audits, investigations, inspections, and other health oversight activities, 10. To comply with Workers’ Compensation laws and other programs that provide benefits for work-related injuries

Our Privacy Pledge CBW has always, and will always respect your privacy. Other than the uses and disclosures we described above, we will not sell or provide any of your Health Information to any outside marketing organization.

Your Individual Rights as a Patient Although your medical record at CBW is the property of CBW, the Health Information it contains belongs to you. The following are rights you have with respect to your Health Information, and a brief description as to how you may exercise these rights.

A. Your right to revoke your authorization You may revoke your authorization to us at any time; however, your revocation must be in writing. There are two circumstances under which we will not be able to honor your revocation request: 1. If we have already released your health information before we receive your request to revoke you authorization, 2. If you were required to give your authorization as a condition of obtaining insurance, the insurance company may have a right to your health information if they decide to contest any of your claims.

If you wish to revoke your authorization please write to us at The Chicago Body Works 3505 N. Ashland Ave. Chicago, IL 60657

B. The right to limit uses or disclosures If there are health care providers, hospitals, employers, insurers or other individuals or organizations to whom you do not want us to disclose your health information, please let us know, in writing, what individuals or organizations to whom you do not want us to disclose your health care information. We are not required to agree to your restrictions. However, if we agree with your restrictions, the restriction is binding on us. If we do not agree to your restrictions, you may drop your request or you are free to seek care from another health care provider.

C. Your right to receive confidential communication regarding your health information We normally provide information about your health to you in person at the time you receive chiropractic services from us. We may also mail you information regarding your health or about the status of your account. We will do our best to accommodate any reasonable request if you would like to receive information about your health or the services that we provide at a place other than your home, or if you would like the information in a different form. To help us respond to your needs, please make any request in writing.

D. Your right to inspect and copy your health information You have the right to inspect and/or copy your health information for seven years from the date that the record was created or as long as the information remains in our files. We require your request to inspect and/or copy your health information to be in writing.

E. Your right to amend your Health Information You have the right to request that we amend your Health Information for seven years from the date that the record was created or as long as the information remains in our files. We require your request to amend your records to be in writing and for you to give us a reason to support the change your are requesting us to make.

F. Your right to receive an accounting of the disclosures we have made, if any, of your Health Information You have the right to request that we give you an accounting of the disclosures we have made of your Health Information for the last six years before the date of your request. The accounting will include all disclosures, except: those disclosures required for your treatment, to obtain payment for your services, or to run our practice (Treatment, Payment or Operations) those disclosures made to you those disclosures necessary to maintain a directory of the individuals in our facility or to individuals involved with your care those disclosures for national security or intelligence purposes those disclosures made to correctional officers or law enforcement officers those disclosures that were made prior to April 14, 2003, the effective date of the HIPAA privacy law

G. Your right to obtain a paper copy of this Notice We will provide a paper copy of this Notice to you, even if you have agreed to accept this notice electronically.

Re-disclosure Information that we use or disclose may be subject to re-disclosure by the person to whom we provide the information and may no longer be protected by the Federal privacy rules.

Your right to complain You may complain to us or to the Secretary for Health and Human Services if you feel that we have violated your privacy rights. We respect your right to file a complaint and will not take any action against you if you file a complaint.

While you may make an oral complaint at any time, written comments should be addressed to: The Chicago Body Works Attention: Privacy Officer 3505 N. Ashland Ave. Chicago, IL 60657

To contact us If you would like further information about our privacy policies and practices please contact: The Chicago Body Works 3505 N. Ashland Ave. Chicago, IL 60657 info@chibodyworks.com